Experiences of graduating students from a medical
programme five years after curricular transformation: A
descriptive study

Centre
for Health Science Education, Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: P McInerney (patricia.mcinerney@wits.ac.za)

Background. The University of the
Witwatersrand introduced a new curriculum in 2003 where students
could gain admission to the medical programme at two levels:
directly as school leavers or following a degree as graduate
entrants at the third year of study. From this point both groups
of students continue in a combined class in a single curriculum.

Objective. To determine the
experiences of the fifth cohort of graduating students from a
medical programme following curricular transformation.

Method. A quantitative descriptive
study was undertaken using a semi-structured questionnaire with
both open- and closed-ended questions. There were 201 students
in the graduating class, all of whom were invited to complete
the questionnaire.

Results. A 74% response rate was
obtained, of which 66% were school leaver entrants and 34% were
graduates. Among the best experiences there were 59 comments
relating directly to the programme. The worst experiences
included perceptions of the lack of standardisation in clinical
exams and feelings of inadequacy in relation to pharmacology and
microbiology. Just under three-quarters of the participants felt
‘adequately prepared’ for the clinical years; 82% of the
participants stated that they would make changes to the
programme.

Conclusion. The placement of this
evaluation at the conclusion of formal assessments may have
contributed to the depth of responses and openness of
respondents in the completion of the questionnaire. We highly
recommend the value of obtaining data on students’ experiences
and opinions of a programme at the point of exit from the
programme.

AJHPE 2013;5(1):34-36. DOI:10.7196/AJHPE.210

The South African medical education curricular landscape has
changed over the last two decades.1 Many of the innovations have
attempted to embrace the ideals of the ‘five-star’ doctor first
espoused by Boelen2 in 1993 and reinforced by
local guidelines from the Health Professions Council of South
Africa (HPCSA).

The focus of these changes has been the development of
student-centred learning and a biopsychosocial approach to
healthcare which is best learnt and delivered at the primary
healthcare level. The development of reflective lifelong
learners is another feature of these innovations.

The University of the Witwatersrand introduced a new curriculum
in 2003.

Students were able to gain admission to the medical programme
at two levels: directly as school leavers or following a degree
as graduate entrants at the third year of study. From this point
both groups of students continue in a combined class in a single
curriculum. It had all the hallmarks of an innovative modern
international curriculum. The transformed curriculum produced
the first graduates in 2006.

Students spent two years in a hybrid problem-based learning
programme arranged in organ-system blocks. The problem-based
learning process is supported by content-based lectures and
learning topics. The teaching of applied anatomy and physiology,
pathology, pharmacology and clinical skills is integrated
together with themes related to the patient-doctor relationship,
the community-doctor relationship and personal and professional
development, including bioethics and evidence-based medicine.
Early clinical exposure was ensured through one health practice
day a week at the teaching hospitals on the academic circuit.

The final two years of the programme were made up of six weekly
rotations through the clinical disciplines, which include an
Integrated Primary Care (IPC) block in the final year. Each of
these rotations is concluded with a summative assessment which
is immediately followed by remediation – if required. Student
learning during this period is guided by a list of case
competencies graded for the level of competence to be attained.
The primary method of instruction remains teaching at the
bedside. The clinical teachers are encouraged to consider the
following during these teaching sessions: epidemiology, patient
communication, quality of care and its evidence base, follow-up
care, the multidisciplinary team, appropriate levels of
healthcare delivery and the impact of resource constraints in
patient management. In 2010, the fifth cohort of students
graduated from the revised curriculum. This group was chosen to
reflect on their experiences of the curriculum in terms of their
achievement of outcomes in the domains of knowledge, skills and
professional behaviour. The objective of the study was to
determine the experiences of the fifth cohort of graduating
students from a medical programme following curricular
transformation.

Curriculum evaluation is integral to curriculum development and
implementation.3
Students are important stakeholders in the curriculum. Graduates
of medical programmes have been followed up at varying intervals
after their graduation4,5 to determine how well they
were prepared for practice. Watmough et
al.6,7 interviewed
graduates from both old and new curricula to compare perceptions
of preparedness for practice. Data collected after graduation
are valuable in that it reflects the experiences of
practitioners, compared with data collected at the point of
graduation which has not been influenced by post-graduation
experiences.8

Methods

A quantitative descriptive study was undertaken using a
semi-structured questionnaire with both open- and closed-ended
questions. The questionnaire established the respondents’ route
of entry to the programme, explored students’ best and worst
experiences of the curriculum, their perceptions of assessment
throughout the curriculum and their perceived level of
preparation for the final two years by the earlier years of the
programme. The respondents were asked what changes they would
make to the programme, if they felt changes were needed. They
were able to make any general comments. Permission to undertake
this study was obtained from the Human Ethics Research Committee
in the Faculty of Health Sciences, University of the
Witwatersrand.

Following their last final examination session, students were
invited to participate in the study through the voluntary
completion of the questionnaire. Subject information sheets and
questionnaires were given to students and a box was provided for
students to return their completed questionnaires anonymously.
Completion of the questionnaire was taken as consent. Responses
to the close-ended questions were captured in an Excel
spreadsheet and the open-ended questions were analysed using a
qualitative approach, where similar responses were grouped
together and categorised.

Results

Of the 201 students in the graduating group, 149 completed the
questionnaire, giving a 74% response rate. Of these, 66% were
school leaver entrants and 34% were graduates, a similar
representation to that of graduates in the class. In an
open-ended question participants were asked to describe their
best and worst experiences of the programme. Among the best
experiences there were 59 comments that related directly to the
programme, with statements such as the ‘integration of the
subject matter’, ‘being taught to think out of the box’,
‘learning to communicate with patients’ and ‘the mix of a
diversity of people in the programme who have different skills
and viewpoints’. There were 31 comments that related directly to
clinical practice, with participants commenting on the
experience of becoming part of the healthcare system and around
relating to patients and their diagnoses compared with learning
facts from a textbook. Among the best experiences were comments
related to the teaching that participants had received – ‘being
taught by the best in the field’. Likewise, several of the worst
experiences also related directly to the programme. Among the 50
comments in this category were the perceptions of the lack of
standardisation in clinical exams and the feelings of inadequacy
in relation to pharmacology and microbiology. Consistent with
the lack of standardisation in the clinical exams were the
comments related to inconsistencies in teaching and learning
methods at the different learning sites. The pressure of
examinations every six weeks were also related to as ‘worst
experiences’.

There were two open-ended questions about assessment, the
first of which asked respondents to comment about their
overall experience of assessment in the programme. Of the 149
respondents, 40 (26.8%) made a global comment that the
assessments were ‘good’, ‘okay’ or ‘fair’, and three did not
answer this question. Many of these respondents were included
among those who elaborated on the assessments. These
additional responses could be categorised into clinical
assessments (61 comments); theoretical assessments (22
comments); and general comments (10 comments). The majority
(54.1%) of the comments about clinical assessment referred to
the subjectivity of the examiners and 18% to the varying
standards between the different clinical sites. Despite the
frequency of examinations being listed in an earlier question
as a ‘worst experience’, only 6.6% of the comments referred to
the frequency of examinations as being a negative factor in
the assessments.

The second of the questions asked participants to comment on
the relationship between learning and assessment. While 46
(30.8%) did not answer this question, 99 (66.4%) gave responses
that could be categorised into clinical assessments, theoretical
assessments and general comments. In the category clinical
assessments there were approximately 2.5 times the number of
negative comments compared with positive comments. The most
commonly mentioned negative comments were that clinical
assessments tend to include aspects not taught in the ward,
because they were not seen; that learning for clinical work and
assessment are two different aspects; assessors’ expectations
being too high for the period of exposure in the discipline; and
a tendency for the ‘most interesting patient’ to be used in
exams. The positive comments were if ‘people were willing to
teach, it made a difference to the assessment’ and that learning
and assessment correlated most of the time. There was a total of
22 comments in the category of theoretical assessment, with the
most frequent comment (10; 45.4%) being that MCQs are not
related to the learning objectives, with the most common
clinical conditions often not being asked. Four participants
felt that the frequency of exams made the assessment exam
driven, resulting in ‘cramming’ for exams. In the general
category were comments such as ‘assessment is not a true
reflection of one’s knowledge’ and ‘projects were often very
time consuming and the amount learned was not proportional to
the time put in’.

Just under three-quarters (107; 72%) of the participants felt
‘adequately prepared’ for the clinical years. Twenty (13%) felt
that they were well prepared and 22 (15%) felt that they were
not prepared. None of the respondents who felt well prepared for
the final years reported a need for change in the early clinical
exposure. In contrast, of those who felt adequately prepared or
unprepared for the final two years 27 (21%) felt that more
clinical exposure would have improved their levels of
preparedness. A participant who felt s/he was adequately
prepared for the clinical years stated ‘I wish I had applied
myself better in GEMP I and II [third and fourth year] in order
to make GEMP III and IV [fifth and sixth year] easier’, and
another wrote ‘you’ll never be prepared clinically to enter the
wards, this comes with time and exposure’. ‘Even though there
was not extensive clinical exposure, the theoretical exposure
gave me some confidence when going to the hospitals’,
demonstrates how participants linked the theoretical and
clinical components of the programme in their responses.

The greater majority (122; 82%) of the participants stated that
they would make changes to the programme. Changes suggested by
111 (91.3%) of this group fell into four categories, i.e.
clinical, theory, teacher and other. The majority of the
suggestions were in the categories clinical (68%) and theory
(71%). The most frequent suggestion in the clinical category was
to begin practical work earlier. In the theory category two
suggestions received an equal number of responses – the request
for specific courses in microbiology and pharmacology and for
some rotations such as internal medicine to be increased in
length. Teacher-related comments were few and each seemed to
address a different aspect. In the ‘Other’ category a range of
comments were made from a request for the administration of the
programme to be improved to a request for a ‘mixer’ at the
beginning of the third year so that the entire class is given an
opportunity to get to know each other.

Discussion

The high response rate of 74% as well as the range and depth of
the responses to the open-ended questions is an indication that
the graduating students appreciated the opportunity to reflect
on their experiences in the programme and express their opinions
on what they found to be most and least valuable. One of the
intentions of the new curriculum was to encourage students to
become reflective practitioners, as suggested by Schön, who
encouraged the integration of theory and practice.9 We
believe that the demonstration of these insights is evidence of
appropriate professional attitudes, one of the attributes of the
five-star doctor. Many of the positive comments related
specifically to integration of theory and practice which
supported problem solving. There are a number of comments that
emphasised the confidence which students felt in their clinical
competence, shown by their feeling of being adequately prepared
for the clinical years.

The negative comments which focused on the subjectivity and
lack of standardisation in assessment of some of the clinical
disciplines raise concern, as standardisation is a necessary
condition for reliability and validity of assessment.10 The
comments on written examinations which are not aligned with
objectives, and the selection of clinical cases with diagnoses
which are not necessarily important or common, are further
indications that issues of content and construct validity may
require further attention. Additional written assignments are
often experienced by students as consuming a greater amount of
time relative to the learning benefits derived. This sentiment
is shared by other students in studies of reflective portfolios.11

The students’ suggestions for earlier clinical practice were
interesting, as the new curriculum actually does introduce
clinical experience a year earlier than prior to 2003. It is
however likely that the time allocated in the weekly ‘health
practice days’ may not be used as effectively as possible and
further changes should be considered. Teaching and learning of
both microbiology and pharmacology remain areas of concern,
confirming the findings of a recent major study in which Smuts
established a gap in these areas of knowledge for recent medical
graduates.12
Smuts compared the performance of interns who were the last
graduates of the old curriculum with the first graduating class
of the new curriculum and found that both groups lacked
confidence in their ability to prescribe. Similar findings have
been reported in other studies,7,13,14 indicating that this
is widely recognised as an area of concern in medical degree
programmes.

One of the limitations of this study was the wide range of
responses obtained in the open-ended questions. This made
analysis and categorisation of results difficult. While this
limited the ability to measure the frequency of a particular
experience, it has highlighted areas for structured
questionnaires in future research.

The findings of the study are valuable as a contribution to the
evaluation of the programme from the point of view of the
participants’ experiences in the acquisition of knowledge and
skills as well as the development of professional attitudes and
behaviours, i.e. levels 1 - 3 of Kirkpatrick’s evaluation model.15 The
placement of this evaluation at the conclusion of formal
assessments may have contributed to the depth of responses and
openness of respondents in the completion of the questionnaire.
The strength of the findings of this study are twofold. Firstly,
respondents had just completed a final assessment in their
programme and yet were prepared to complete the questionnaire as
evidenced by just under three-quarters of the class returning
the questionnaire. Furthermore, respondents did not confine
themselves to the space provided for each question. Several
wrote in the margins or made use of space at the bottom of the
page, demonstrating the students’ commitment to providing
constructive feedback on the programme. Their responses
demonstrated considered thought to educational concepts. As a
result, important areas have been identified for curricular
modification and further faculty development. We highly
recommend the value of obtaining data on students’ experiences
and opinions of a programme at the point of exit from the
programme.

11. Rees CE,
Shepherd M, Chamberlain S. The utility of reflective
portfolios as a method of assessing first year medical
students’ personal and professional development. Reflective
Practice: International and Multidisciplinary Perspectives
2011;6(19):3-14.
[http://dx.doi.org/10.1080/1462394042000326770]

11. Rees CE,
Shepherd M, Chamberlain S. The utility of reflective
portfolios as a method of assessing first year medical
students’ personal and professional development. Reflective
Practice: International and Multidisciplinary Perspectives
2011;6(19):3-14.
[http://dx.doi.org/10.1080/1462394042000326770]

12. Smuts KB.
Effects of Curriculum Change on Medical Graduates’
Preparedness for Internship. Johannesburg: University of the
Witwatersrand, 2011.

12. Smuts KB.
Effects of Curriculum Change on Medical Graduates’
Preparedness for Internship. Johannesburg: University of the
Witwatersrand, 2011.

14. Han WH,
Maxwell SRJ. Are medical students adequately trained to
prescribe at the point of graduation? Views of first year
foundation doctors. Scott Med J 2006;51(4):27-32.
[http://dx.doi.org/10.1258/rsmsmj.51.4.27]

14. Han WH,
Maxwell SRJ. Are medical students adequately trained to
prescribe at the point of graduation? Views of first year
foundation doctors. Scott Med J 2006;51(4):27-32.
[http://dx.doi.org/10.1258/rsmsmj.51.4.27]